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• Private Practice-Columbus, Ohio

• Former Assistant Clinical Professor:The Ohio State University-13 years

Daniel H Ward DDS

• Fellow Academy of General Dentistry

• Fellow American College of Dentists

• Fellow International College of Dentists

• Fellow American Society for Dental Aesthetics

• Associate Member American Academy of Esthetic Dentistry

Daniel H Ward DDS

•• Dr Harry AlbersDr Harry Albers•• Dr Paul BelvedereDr Paul Belvedere•• Dr John BurgessDr John Burgess•• Dr Mark CanonDr Mark Canon•• Dr Gordon ChristensenDr Gordon Christensen•• Dr George FreedmanDr George Freedman•• Dr Doug LambertDr Doug Lambert•• Dr Karl Dr Karl LeinfelderLeinfelder•• Dr Graeme Dr Graeme MilicichMilicich•• Dr Buddy Dr Buddy MopperMopper•• Dr Brian Dr Brian NovyNovy•• Dr Jorge Dr Jorge PerdagPerdagãoão•• Dr Robert Dr Robert SeghiSeghi•• Dr Irwin Dr Irwin SmigelSmigel•• Dr Dr ByongByong SuhSuh•• Dr Ed SwiftDr Ed Swift

“Oh, I Get By With a Little Help from my friends…..

Photographic Disclosure

• Some Images were:• Cropped• Rotated• Levels adjusted

• No images were:• Site adjusted• Enhanced to produce a better

resultMusic

Universal Language

♪♫♪♫♪♫

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Smile

Universal Language Communication

Emotions

“The smile is a way of expressing on the outside our feelings on the inside”

Equally Qualified

Congratulations,

You’re hired!

Communication: Success

Excess Gingival Display

Excessive gingival display negatively affected how attractive a person's smile is judged to be. In addition, how friendly, trustworthy, intelligent, and self-confident a person was perceived to be was inversely related to the amount of gingival display. Laypeople were just as sensitive to these differences as dental students.

Communication: Perception

Malkinson S1, Waldrop TC, Gunsolley JC, Lanning SK, Sabatini R. The effect of esthetic crown lengthening on perceptions of a patient's attractiveness, friendliness, trustworthiness, intelligence, and self-confidence. J Periodontol. 2013 ;84:1126-33.

Plain looking individuals made 5-10% less per year

A ttractive persons made 4-8% more per year(based on their own personal opinion of their appearance)

In 2014:

Median US household yearly

salary was

$53,891*

According to a recent survey:

*Sentier Research Group as cited http://money.cnn.com/2014/08/20/news/economy/median-income/

Why Do People Seek Cosmetic Dentistry?

AACD Survey 2013

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Confidence, warmth, friendliness, the eyes!

Successful Attitude

Tom Cruise

Who is This?

Hilliary Duff

Ben AffleckCheryl Cole

So you don’t think a smile is Important?

George ClooneyCatherine Zeta-Jones

The Stars know!!

Smile

Dr Guillaume Duchenne

Guillaume-Benjamin Duchenne de Boulogne“Mechanism of Human Physiognomy or Electro-physiological Analysis of the Expression of the Passions ”

• 1840’s Paris physician• Applied electrodes to

guillotine patients• Muscles contract into facial

expressions• First to demonstrate

mechanism of smiling

What is a Smile?

Dr Guillaume Duchenne

“Smiling constitutes a universal language which neither fashions nor whims can change …and is the same in all people…”

Guillaume-Benjamin Duchenne de Boulogne“Mechanism of Human Physiognomy or Electro-physiological Analysis of the Expression of the Passions ”

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Smile Muscles

Muscles of Facial Expression

• Zygomatic• Buccinator• Obicularis Oris• Triangularis

What is a Smile?

“…The smile offers a convenient shorthand for far-reaching assessments of character, behavior, and temperament. ” 2004 Angus Trumble “A Brief

History of the Smile ”

Angus Trimble

What is a Smile?

Richard Conniff

Smithsonian 2007“What’s behind a Smile?”

“Our facial expressions, and especially the smile, constitute a system of unconscious communication that got built into our biology long before language itself”

What is a Smile?

“Smiles in fact are only the most visible part of an intimate melding between two minds”

New York Times 2011

Words Used to Describe Smiles

http://www.macmillandictionary.com/us/thesaurus-category/american/words-used-to-describe-smiles

“Brittle Smile”• a brittle laugh or smile does not

show real humor or happiness

“Cheesy Smile”• a cheesy smile is very obvious but

looks false laugh or smile does not show real humor or happiness

“Humorless Smile”• a humorless smile expresses no

pleasure

Words Used to Describe Smiles

http://www.macmillandictionary.com/us/thesaurus-category/american/words-used-to-describe-smiles

“Mirthless Smile”• a mirthless smile or laugh

expresses feelings such as anger or sadness

“Mona Lisa Smile”• used for describing a mysterious

smile or expression on a woman’s face

“Sardonic Smile”• a sardonic smile, expression, or

comment shows a lack of respect for what someone else has said or done

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Words Used to Describe Smiles

http://www.macmillandictionary.com/us/thesaurus-category/american/words-used-to-describe-smiles

“Set Smile”• a set smile or expression does not

change, and often hides what someone is really thinking

“Sly Smile”• a sly smile shows that the person

doing it knows something that other people do not know

“Thin Smile”• if someone gives a thin smile,

their lips move but the feeling is not sincere FACIAL TRIANGLE

Smiles are part of the FACE

Facially Generated Dental Esthetics

Multi-disciplinary Approach

• Orthodontics• Periodontics• Prosthodontics• Facial Plastic

Surgeon

Dr. David Sarver

Introduction to Smile Design

•There are rules•Rules are made to be

broken•No one smile ever

follows all the rules

•Let’s start with a blank canvas

•Where do we begin?

Designing an Ideal Smile

Incisal edge is starting point!

•Incisal plane parallel to the interpupillaryline

Incisal Placement

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Canted Incisal Plane

•Forehead - from Trichion to Nasion

•Cheek - Nasion to Subnasale

•Mouth - Subnasaleto Menton

Trichion

Nasion

Subnasale

Menton

Rule of Thirds

•Divide subnasale and menton into equal Thirds

•Incisal edge at junction of Superior and Middle Thirds

Incisal Edge

Rule of Thirds Incisal Plane too inferior

Incisal Plane too superior

•Appearance

Determinents of Incisal Edge Placement:

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•Appearance•Phonetics

Determinents of Incisal Edge Placement:

Use words like “these, those, fifty five, very fine”

Pound- JPD 1970“Using speech to simplify

denture service”

“When the patient pronounces “f” and “v”sounds…the length and labiolingual position of the incisal edges of the maxillary teeth…can be determined.”

Incisal Edge Position:Phonetics

•Appearance•Phonetics•Occlusion

Determinants of Incisal Plane Placement:

•Vertical midline in the center of the face perpendicular to the interpupillary line

•Vertical midline centered with the philtum

Incisal Placement

Smile CurveReverse Smile Curve

•Incisal edges follow curvature of the lower lip

Incisal Placement

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The anterior-posterior curvature of the occlusal plane superiorly as you move distally

Curve of Spee Curve of Spee-Flat

•Clinical crown outlined by the upper and lower lip

•Marginal gingiva display confined to interdental papilla

Tooth Display

•Altered Passive Eruption

Excess Gingival Display

•Buccal Corridor•Negative Space

Smile Display

•Display of posterior buccal teeth

Smile DisplayFilling the Buccal Corridor

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Roots diverge apically as you move distally-anteriors

Roots converge apically as you move distally-anteriors

Incisal embrasures become larger as you move distally

Roots diverge apically as you move distallyContact points move apically as you move distally

Roots diverge apically as you move distallyConnector Area

Morley J –Prac Perio Aesth Dent 2000 “A multidisciplinary approach to complex

aesthetic restoration with diagnostic planning”

50%

40%

30%

•Connector area is the perceived area where the two teeth appear to touch•Percentage is of height of tooth•Contact point is usually 2mm or less

Apical Zenith located distal to the long axis midline

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Roots diverge apically as you move distallyCervical of Central Incisors and Cuspids are parallel

Roots diverge apically as you move distallyIncisal and cervical length of laterals may be 0.5-1mm shorter than Central Incisor

Feminine

Roots diverge apically as you move distallyIncisal and cervical length of laterals may be 0.5-1mm shorter than Central Incisor

Masculine

•Central Incisor:DOMINANCE

•Lateral Incisor:VARIABILITY

•Cuspid:AGGRESIVENESS

Factors affecting each tooth in the smile

Morley – Dentistry Today 1990“Design Theory of Central

Incisors”

Central IncisorsMirror Images

Frush & Fisher - JPD 1957“The Age Factor in Dentogenics”

Central IncisorsSPA factor-Age

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Central Incisors

• Geometric shape is trapezoidal

• Mesial crest of convexity is in the incisal third

• Distal profile is more convex and the crest of convexity is at the junction of the middle and incisal thirds

• Mesial incisal angle is almost a right angle, distal incisal line angle is rounded

Roots diverge apically as you move distallyRelationship of Face Form and Tooth Form

Denture teeth often recommend tooth form to mimic face form

Dr.Galip Gurel

Correlating Face and Personality

• Dynamic• Delicate• Stability

Relationship of Face Form and Tooth Form

Lateral Incisors-Diversity SPA Factor Sex

Frush & Fisher - JPD 1956“How Dentogenic Restorations

Interpret the Sex Factor”

MasculineFeminine

Lateral Incisors

• Smaller and more rounded than the central incisor

• Mesial crest of convexity is in the incisal third

• Distal crest of convexity is in the middle third

• The incisal edge and incisal angles are more curved than the central Masculine Feminine

Roots diverge apically as you move distallyMasculine vs feminine

Feminine

•Rounded facial profile

•Shorter lateral incisor

•Apical zenith-lateral centered

•Narrow gingival width of LI

•Rounded incisal forms

Lombardi - JPD 1973“The principles of visual

perception and their clinical application to denture esthetics”

Research show no difference in extracted teeth from male

to female;

However

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Masculine vs feminine

FeminineMasculine

Cuspids-AggresivenessSPA Factor-Personality

Frush & Fisher - JPD 1956“How Dentogenics Interprets the

Personality Factor”

AggressivePassive

Cuspids

• Cusp tip mesial to crown center

• Mesial crest of convexity at the junction of middle and incisal thirds

• Distal crest of convexity-prominent bulge in the middle third of the crown

• Distinct developmental depressions

Whose smile is this?

Brad Pitt

Whose smile is this?

Kate Middleton

Whose smile is this?

Will Smith

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Whose smile is this?

Julia Roberts

Whose smile is this?

Halle Berry

Whose smile is this?

Angelina Jolie

Roots diverge apically as you move distallyNatural Aging of the Face

•Modified Rule of ThirdsPowell N, Humphreys B. Proportions of the Aesthetic Face.

New York. Thieme-Stratton, 1984.

Roots diverge apically as you move distallyNatural Aging of a Smile

•Flattened, worn incisal edges

•Smaller incisal embrasures

•Smoother facial anatomy

•Display-mandibular teeth

•Increased chroma

•Anterior Splaying

Vig RG, Brundo GC. The kinetics of anterior tooth display. J Prosthet Dent 1978; 39:502-

504.

Roots diverge apically as you move distallyCreating a Younger Smile

•Textured incisal edges

•Pronounced incisal embrasures

•Mammelons, developmental grooves, perikymata, lines of Retzius

•Prominent maxillary teeth display

•Increased value, Hunter-Schregerbands, incisal translucency

Morley J. The Role of Cosmetic Dentistry in Restoring a Youthful Appearance. JADA

1999; 130:1166-1172.

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Roots diverge apically as you move distallyCompensate for Discrepancies by Creating Illusions-Width

Narrow Wide

NarrowWide

Roots diverge apically as you move distallyCompensate for Discrepancies by Creating Illusions-Height

Curved

Flat

(Short)

(Tall)

Roots diverge apically as you move distallySmile Shapes

by Dr Bill Dickerson

Smile Shapes

From “The Smile Catalog”

TM The Ultimate Practice Inc

Smile Shapes

From “The Smile Catalog”

TM The Ultimate Practice Inc

Smile Shape Guides From “The Smile Guide”

TM Discus Enterprises

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Traditional Dentistry

• Teeth• Periodontium• Occlusion• Periodontal

Architecture

Traditional Dentistry Components

• Visual Exam• Tactile Exam• Diagnostic Casts• Radiographs

Objective Tooth Evaluation Cosmetic Dentistry

Aesthetic DentistryFounding Father

NYU and the curator for the

Smithsonian Institute credit

Dr. Irwin Smigelwith being the

“Father of Aesthetic

Dentistry”

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• Teeth• Periodontium• Occlusion• Periodontal

Architecture• Lips • Facial Muscles• Skeletal structure• Soul

Cosmetic Dentistry Components

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Who has an ideal smile?

How do we diagnose a smile?

Subjective Smile Evaluation

TLAR Principle

Evaluation Methods

Objective Smile Evaluation

Proportional Smile Design

Evaluation Methods

Objective Smile Evaluation

Evaluation Methods

Chair-side Smile Evaluation

Evaluation Methods

Evaluate this smile

Evaluate this smile

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Describe this smile Chair-side Visual Evaluation?

Evaluation Methods

Diagnostic Casts Evaluation

Objective Smile Evaluation

LaboratoryWaxup

• Lips • Facial Muscles• Skeletal structure• Soul

Diagnostic Casts?

• Evaluate all smile components

• Unlimited Time Factor

• Measure relative tooth dimensions

• Predictable Results

CHALLENGE

Objective Smile Evaluation

Objective Smile Evaluation

PredictableCosmetic DentistryCannot be

achieved without the use of: PHOTOGRAPHY

Using Photographyto

Design Smiles

“My wife wants me to do a smile makeover”

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Using Photographyto

Design Smiles

“I just don’t like the gray spots. I want whiter teeth!”

Using Photographyto

Design Smiles

High Occlusion

Using Photographyto

Design Smiles

Treatment Options

Implant # 10

Lingual composites # 9 & #11

“I just don’t like the gray spots. I want whiter teeth!”

Using Photographyto

Design Smiles

Treatment Options

Implant # 10

Crowns # 9 & #11

Using Photographyto

Design Smiles

Treatment Options

Implant # 10

Crowns # 9 & #11

Using Photographyto

Design Smiles

Challenges

Replace missing tooth

Change cant

Whiten smile

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Using Photographyto

Design Smiles

Recommended Treatment

•All-porcelain bridge#9-11•Porcelain laminateveneers #5,6-8,12

Using Photographyto

Design Smiles

Accepted Treatment

•All-porcelain bridge#9-11•Porcelain laminateveneers #6-8

Using Photographyto

Design Smiles

Preparations

Using Photographyto

Design Smiles

Seating

Soft Tissue Model

Using Photographyto

Design Smiles

Completed Case